DS9 Document EFTA00313928

Name: F E_PSTEJ Date of Birth: TA ri - * Height: ()E I I " Weight: I 7' Social Security I: Some of the following items m.ay be hazardous to your safety or can interfere with you MRIIMRA examination. Please check YES or NO for each of the following items. YES NO Cardiac Pacemaker or Deflbrelator Brain Aneurysm clip (s) Transdermal Patch: Nicotine / Nitroglycerine Shunts (e.g. Spinal I intraventriculad VP shunt) Bone Growth /Fusion stimulator Newesemulator Cochlear /Otologic / Ear Implant Implanted Drug Infusion Device / insulin Pump Electrodes (on body, heed or brain) Any implant Held In Piece by Magnet Carotid Men/ Vascular Clamp Intravasc.lar stents, fitters, or cols Vasatlar Access Port and/or Catheter Swan-Gana Catheter Internal Pacing Wires My type of prosthesis: eye,penile. etc Metal or Wire Mesh Implants Harrington Rods (spine) Joint Replacement Bone/Joint On, screw, nail, wire, plate 80470= 61e 60 Tattooed Makeup (eyeliner, ups, Mc) Any Metal Fragments IUD or Diaphragm Hearing ad (remove bebre MRI/MRA) Dentures (remove Debra MRI/MRA) Asthma or other breathing disorder Arudsty Other:* 1. What problems are you having that made the doctor order thlis sbxty? 2. have you ever been to the hospital for an invasive procedures or surgery? Yes / No Dale Reason 3. Have you ever had an accident that required metal fragments to be removed from your eye? 4_ Werner.; Could you 4:41 pregnant? Yea / No 5. Do you have a history of kidney disease? Yes / No 6. Do you have sickle cell anemia? Yes / No 7. Have you had an allergic reaction that required emergency treatment? Yes / No 8. Do you or have you: High blood pressure?Yes / No Diabetes? Yes / No High cholesterol? Yes I No Smoked tobacco? Yes / No 9. Do you have chest pain? Yes / No If yes Is it substemal? Yes / No Is it brought on by exertion or emotional stress? Yes / No is it relayed by rest or nitrogdycarine? Yes I No Patient Signature: Date: JAI 1-. ? stRi Screerme Form.: 10/22112 EFTA00313928